Fatal flaw: Some doctors suggest that the modern definition of 'death' is wrong -- and that the mistake is costing lives.

The question has long influenced decisions about when it's appropriate to end medical treatment for people who are hopelessly ill. However, a quieter debate has simmered for years about how the concept of death informs the practice of organ transplantation. Transplant surgeons rely on strict definitions of death to reassure would-be donors. Wary of the macabre suggestion that they are willing to exploit the dying for their organs, surgeons abide by a code known as the "dead donor rule," which forbids removing body parts from the living.

Yet a few outspoken medical ethicists say the dead donor rule is broken all the time -- and, perhaps even more surprising, that the rule itself should be abandoned. The dead donor rule, they argue, prevents some terminally ill patients from donating organs, even if they want to. And, they say, it has become clear that doctors will never be able to devise a coherent definition of death. Even the concept of "brain death," the diagnosis of most deceased organ donors, falls apart on closer examination. Why not, they ask, simply admit that some people donate vital organs when they are, in some important way, still alive?

"It's completely ethical to remove organs from patients we diagnose as brain dead," says Dr. Robert Truog, director of clinical ethics at Harvard Medical School and a physician at Children's Hospital Boston. "It's just ethical for reasons other than that we think they're dead, because I don't think they are."

Truog is one of a handful of vocal critics who believe the medical community is misleading the public -- and deluding itself -- with an arbitrary definition of death. The debate, which is being fought largely in academic journals, has important implications for the modern enterprise of transplantation, which prolonged the life of more than 28,000 Americans last year. Truog and other critics believe that changing the rules -- and the bright-line concept of death that underlies them -- could mean saving more of the 6,500 Americans who die every year waiting for an organ.

Although Truog says many doctors have problems with the concept of brain death, it is an established medical and legal standard. And its numerous defenders worry that allowing organs to be taken from people who haven't completely died, or even discussing it, would greatly compromise the public's confidence in organ transplantation.

"There is no controversy about brain death," says Dr. Eelco Wijdicks, a Mayo Clinic neurologist and a leading authority on the topic. Wijdicks says the concept is widely embraced by neurosurgeons and neurologists. Claims by "brain death rejecters" that the concept is flawed, he says, don't jibe with his clinical experience. "What they describe is not what we see."
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